What is the recommended management for acute appendicitis?

Management of Acute Appendicitis

Laparoscopic appendectomy within 24 hours of admission is the recommended first-line treatment for acute appendicitis, offering superior outcomes in terms of mortality, morbidity, and quality of life compared to both delayed surgery and non-operative management. 1, 2

Surgical Management: The Gold Standard

Laparoscopic appendectomy should be performed as the preferred approach for both uncomplicated and complicated acute appendicitis where laparoscopic equipment and expertise are available, as it provides significant advantages over open appendectomy including less postoperative pain, lower surgical site infection rates (75% reduction), shorter hospital stays, earlier return to work, and better quality of life scores. 1, 2

Timing of Surgery

• Surgery must be performed within 24 hours of admission to minimize complications and adverse outcomes, as delays beyond this timeframe significantly increase the risk of perforation, surgical site infections, and morbidity. 1, 2, 3
• For complicated appendicitis (perforation, abscess, peritonitis), early appendectomy within 8 hours should be performed, as this approach demonstrates lower incidence of bowel resection (3.3% vs 17.1%) compared to initial non-operative management. 1, 2, 3
• Delays beyond 48 hours dramatically increase surgical site infections and adverse events. 4

Technical Considerations

• Conventional three-port laparoscopic appendectomy is preferred over single-incision techniques due to shorter operative times, less postoperative pain, and lower wound infection rates. 1, 2
• Simple ligation of the appendiceal stump using endoloops/suture ligation or polymeric clips is recommended over stump inversion. 2, 3, 4
• Remove the appendix even if it appears normal during surgery in symptomatic patients, as macroscopic judgment is inaccurate and 27.8% of "normal-appearing" appendices show inflammation on histopathology. 2, 4
• Perform suction alone rather than peritoneal irrigation in complicated appendicitis, as irrigation provides no benefit in preventing intra-abdominal abscess formation. 1, 4
• Do not place abdominal drains following appendectomy for complicated appendicitis, as they provide no benefit and lead to longer hospitalization. 2, 4

Antibiotic Protocol

Preoperative Antibiotics

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision for all patients undergoing appendectomy. 2, 3, 4

Postoperative Antibiotics

• For uncomplicated appendicitis with adequate source control: Do not administer postoperative antibiotics. 2, 4
• For complicated appendicitis: Continue antibiotics for 3-5 days postoperatively when adequate source control has been achieved, then discontinue. 2, 3, 4

Non-Operative Management: Limited Role

Non-operative management with antibiotics can be discussed as an alternative in highly selected patients with uncomplicated acute appendicitis and absence of appendicolith, but patients must be counseled about the significant limitations. 1, 3

When to Consider Antibiotics-First Approach

• Only for uncomplicated appendicitis without appendicolith on imaging. 1, 5
• Patient must be informed that approximately 30% will require appendectomy within one year (or conversely, only two-thirds avoid surgery). 2, 6
• High-risk CT findings (appendicolith, mass effect, appendiceal diameter >13 mm) are associated with 40% treatment failure rates and should prompt surgical management. 5

Antibiotic Regimen for Non-Operative Management

• Initial intravenous antibiotics (piperacillin-tazobactam monotherapy, or cephalosporins/fluoroquinolones with metronidazole) with subsequent switch to oral antibiotics based on clinical improvement. 1, 5
• Total duration typically 8-15 days. 7

Success Rates and Limitations

• At one year, only 63-73% of antibiotic-treated patients remain asymptomatic without complications or recurrence, compared to 97% success with immediate appendectomy. 7, 6
• Antibiotics may reduce wound infections but result in 76 more unsuccessful treatments per 1000 people compared to surgery. 6

Special Populations

Pregnant Patients

• Laparoscopic appendectomy is preferred over open surgery when surgery is indicated, as it is safe in terms of fetal loss and preterm delivery risk, with shorter hospital stays and lower surgical site infection rates. 1
• Short in-hospital delay with observation and repeated ultrasound is acceptable for equivocal cases. 1

Pediatric Patients

• Laparoscopic appendectomy is recommended where expertise is available, with surgery performed within 24 hours for uncomplicated cases. 1
• Early appendectomy within 8 hours for complicated appendicitis. 1
• Non-operative management with antibiotics can be discussed in children with uncomplicated appendicitis without appendicolith, though evidence is weaker than in adults. 1

High-Risk Surgical Patients

• Laparoscopic appendectomy is suggested for obese patients, older patients, and those with comorbidities, as it shows relevant advantages over open surgery. 1
• In settings without laparoscopic expertise for complicated cases, non-operative management with antibiotics and percutaneous drainage (if available) is suggested. 2

Patients ≥40 Years Old

• Both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended for follow-up after complicated appendicitis due to higher incidence of appendicular neoplasms (3-17%). 2
• The incidence of malignancy in the antibiotic-treated group is 0.3%, though follow-up data are variable. 6

Mandatory Follow-Up Measures

• Routine histopathological examination of all removed appendices is mandatory to identify unexpected findings, including malignancy. 2, 3, 4
• Interval appendectomy is NOT routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years) and children, but should be performed for those with recurrent symptoms. 2

Critical Pitfalls to Avoid

• Never delay appendectomy beyond 24 hours from admission for patients requiring surgery, as this significantly increases adverse outcomes. 1, 2, 4
• Do not rely on macroscopic appearance during surgery—remove the appendix even if it appears normal in symptomatic patients. 2, 4
• Avoid single-incision laparoscopic techniques as they are associated with longer operative times, higher analgesic requirements, and higher wound infection rates. 1, 4
• Do not use peritoneal irrigation routinely during laparoscopic appendectomy, as it provides no benefit. 1, 4
• Do not place drains after appendectomy for complicated appendicitis. 2, 4
• Maintain low threshold for conversion to open surgery in complicated appendicitis with shock or technical difficulties. 4
• Do not fail to follow up patients ≥40 years old with appropriate imaging and colonoscopy due to malignancy risk. 2